Jonathan F. Dickens

Return to Play and Recurrent Instability After In-Season Anterior Shoulder Instability A Prospective Multicenter Study

Background: There is no consensus on the optimal treatment of in-season athletes with anterior shoulder instability, and limited data are available to guide return to play. Purpose: To examine the likelihood of return to sport and the recurrence of instability after an in-season anterior shoulder instability event based on the type of instability (subluxation vs dislocation). Additionally, injury factors and patient-reported outcome scores administered at the time of injury were evaluated to assess the predictability of eventual successful return to sport and time to return to sport during the competitive season. Study Design: Cohort study (prognosis); Level of evidence, 2. Methods: Over 2 academic years, 45 contact intercollegiate athletes were prospectively enrolled in a multicenter observational study to assess return to play after in-season anterior glenohumeral instability. Baseline data collection included shoulder injury characteristics and shoulder-specific patient-reported outcome scores at the time of injury. All athletes underwent an accelerated rehabilitation program without shoulder immobilization and were followed during their competitive season to assess the success of return to play and recurrent instability. Results: Thirty-three of 45 (73%) athletes returned to sport for either all or part of the season after a median 5 days lost from competition (interquartile range, 13). Twelve athletes (27%) successfully completed the season without recurrence. Twenty-one athletes (64%) returned to in-season play and had subsequent recurrent instability including 11 recurrent dislocations and 10 recurrent subluxations. Of the 33 athletes returning to in-season sport after an instability event, 67% (22/33) completed the season. Athletes with a subluxation were 5.3 times more likely (odds ratio [OR], 5.32; 95% CI, 1.00-28.07; P = .049) to return to sport during the same season when compared with those with dislocations. Logistic regression analysis suggests that the Western Ontario Shoulder Instability Index (OR, 1.05; 95% CI, 1.00-1.09; P = .037) and Simple Shoulder Test (OR, 1.03; 95% CI, 1.00-1.05; P = .044) administered after the initial instability event are predictive of the ability to return to play. Time loss from sport after a shoulder instability event was most strongly and inversely correlated with the Simple Shoulder Test (P = .007) at the time of initial injury. Conclusion: In the largest prospective study evaluating shoulder instability in in-season contact athletes, 27% of athletes returned to play and completed the season without subsequent instability. While the majority of athletes who return to sport complete the season, recurrent instability events are common regardless of whether the initial injury was a subluxation or dislocation.

Management of mid-season traumatic anterior shoulder instability in athletes.

&NA; Shoulder dislocation and subluxation injuries are common in young athletes and most frequently occur during the competitive season. Controversy exists regarding optimal treatment of an athlete with an in‐season shoulder dislocation, and limited data are available to guide treatment. Rehabilitation may facilitate return to sport within 3 weeks, but return is complicated by a moderate risk of recurrence. Bracing may reduce the risk of recurrence, but it restricts motion and may not be tolerated in patients who must complete certain sport‐specific tasks such as throwing. Surgical management of shoulder dislocation or subluxation with arthroscopic or open Bankart repair reduces the rate of recurrence; however, the athlete is unable to participate in sport for the remainder of the competitive season. When selecting a management option, the clinician must consider the natural history of shoulder instability, pathologic changes noted on examination and imaging, sport‐ and position‐specific demands, duration of treatment, and the athletes motivation.

Subpectoral Biceps Tenodesis An Anatomic Study and Evaluation of At-Risk Structures

Background: The neurovascular structures of the proximal arm may be at risk for iatrogenic injury during open subpectoral biceps tenodesis (OSPBT). Purpose: To define the anatomic relationships and at-risk structures during OSPBT and to quantify the effect of arm rotation on the position of the musculocutaneous nerve. Study Design: Descriptive laboratory study. Methods: The OSPBT approach was performed in 17 unembalmed cadaveric upper extremities. The tenodesis site was inferior to the bicipital groove and positioned so the musculotendinous portion of the long head of the biceps rested at the inferior border of the pectoralis major. A meticulous dissection identified the brachial artery, deep brachial artery, cephalic vein, brachial vein, medial brachial cutaneous nerve, medial antebrachial cutaneous nerve, intercostal brachial cutaneous nerve, musculocutaneous nerve, axillary nerve, median nerve, and radial nerve. Superficial structures were measured from the superior and inferior aspects of the incision, and deep structures were measured from the tenodesis site and nearest retractor. The musculocutaneous nerve was measured with the arm in neutral, internal, and external rotation. Results: The musculocutaneous nerve was 10.1 mm (range, 6-18 mm) medial to the tenodesis location and 2.9 mm (range, 1-6 mm) medial to the medially placed retractor in neutral arm position. The radial nerve and deep brachial artery were 7.4 mm (range, 2-12 mm) and 5.7 mm (range, 1-10 mm) deep to the medially placed retractor, respectively. With the arm internally rotated to 45°, the musculocutaneous nerve was 8.1 mm from the tenodesis site, compared with 19.4 mm with the arm 45° externally rotated (P = .009). The median nerve, brachial artery, and brachial vein were >2.5 cm from the tenodesis site and nearest retractor during deep dissection. Conclusion: The musculocutaneous nerve, radial nerve, and deep brachial artery are within 1 cm of the standard medial retractor. External rotation of the arm moves the musculocutaneous nerve 11.3 mm further away from the tenodesis site compared with the internally rotated position. Clinical Relevance: The musculocutaneous nerve, radial nerve, and deep brachial artery course in close proximity to the operative field and are therefore at risk during OSPBT. Limiting the use of medial retraction and placement of the arm in an externally rotated position will minimize neurovascular injury.

Epidemiology of Meniscal Injury Associated With ACL Tears in Young Athletes

The epidemiologic characteristics of concomitant meniscal tears that occur at the time of anterior cruciate ligament (ACL) injury have been variably reported. The purpose of this study was to assess the epidemiology of meniscal tears that occur in the ACL-injured knee of a young, athletic population at a single institution. We were unable to find a difference in meniscal tear incidence based on sex, mechanism of injury, sport, or time to surgery. In addition, we found that the cumulative incidence of isolated medial meniscal tears was significantly higher than the cumulative incidence of isolated lateral meniscal tears. Our prospective study design and ability to identify and follow all patients in our study population make this a unique study.

Reported Concussion Rates for Three Division I Football Programs An Evaluation of the New NCAA Concussion Policy

Background: There has been increased interest in the number of concussions occurring in college football over the past year. In April 2010, the National Collegiate Athletic Association (NCAA) published new guidelines for the diagnosis and treatment of concussions in student athletes. Purpose: To determine the number of concussions that occurred on 3 collegiate Division I military academy football teams prior to and following recent changes in the NCAA concussion management policy. Study Design: Descriptive epidemiology study. Methods: Injury reports were reviewed from 3 Division I military academy football teams. The number of concussions that occurred over the 2009-2010 and 2010-2011 seasons, including those sustained in practice and game situations, was determined for each team. Incidence rates were compared using the exact binomial method. Results: The combined concussion incidence rate doubled from 0.57 per 1000 athlete exposures in the 2009-2010 season to 1.16 per 1000 athlete exposures in the 2010-2011 season (incidence rate ratio, 2.04; 95% CI, 1.2-3.55; P = 0.01). The combined numbers of concussions for the 2009-2010 and 2010-2011 seasons were 23 (40,481 exposures) and 42 (36,228), respectively. Conclusion: The combined incidence rate of concussions for the 2010-2011 season doubled from the previous season after the implementation of new NCAA policies on concussion management. While the institution of a more formalized concussion plan on the part of medical staff is one possible factor, another may have been the increased recognition and reporting on the part of players and coaches after the rule change.

Joint Space Narrowing After Partial Medial Meniscectomy in the Anterior Cruciate Ligament-Intact Knee

Abstract Osteoarthritis of the knee is common after total medial meniscectomy. In anterior cruciate ligament‐intact knees, the reported outcomes of partial medial meniscectomy are variable. Radiographic assessment using a posteroanterior weight‐bearing view is a reliable tool for detecting minor medial joint space narrowing, which may be an early sign of osteoarthritis. Studies that assessed the effect of partial medial meniscectomy found a low percentage of patients with >50% joint narrowing at 10 to 15 years after surgery. Digital radiography, using a posteroanterior weightbearing view, is a highly sensitive method for observing minor joint space narrowing in the involved knee. A recent study showed that 88% of patients who underwent partial medial meniscectomy had joint space narrowing of <2 mm, and none had narrowing ≥2 mm, at a mean follow‐up of 12 years. Subjective results after partial medial meniscectomy are favorable, with 88% to 95% of patients reporting good to excellent results.

Outcome of Grade I and II Hamstring Injuries in Intercollegiate Athletes: A Novel Rehabilitation Protocol

Background: Hamstring muscle strains represent a common and disabling athletic injury with variable recurrence rates and prolonged recovery times. Objectives: To present the outcomes of a novel rehabilitation protocol for the treatment of proximal hamstring strains in an intercollegiate sporting population and to determine any significant differences in the rate of reinjury and time to return to sport based on patient and injury characteristics. Study Design: Retrospective case series. Methods: A retrospective review was performed of 48 consecutive hamstring strains in intercollegiate athletes. The rehabilitation protocol consisted of early mobilization, with flexible progression through supervised drills. Athletes were allowed to return to sport after return of symmetrical strength and range of motion with no pain during sprinting. Primary outcomes included time to return to sport and reinjury rates. Results: All patients returned to their sports, and 3 sustained repeat hamstring strains (6.2% reinjury rate) after a minimum follow-up of 6 months. The average number of days missed from sport was 11.9 (range, 5-23 days). There was no statistically significant difference for time to return to sport between first-time and recurrent injuries and between first- and second-degree injuries (P > 0.05). Conclusions: Grade I and II hamstring strains may be aggressively treated with a protocol of brief immobilization followed by early initiation of running and isokinetic exercises—with an average expected return to sport of approximately 2 weeks and with a relatively low reinjury rate regardless of injury grade (I or II), injury characteristics (including first-time and recurrent injuries), or athlete characteristics.

Return to Play Following Anterior Shoulder Dislocation and Stabilization Surgery.

Anterior shoulder instability in athletes may lead to time lost from participation and decreases in level of play. Contact, collision, and overhead athletes are at a higher risk than others. Athletes may successfully be returned to play but operative stabilization should be considered for long-term treatment of recurrent instability. Open and arthroscopic stabilization procedures for athletes with less than 20% to 25% bone loss improve return to play rates and decrease recurrent instability, with a slightly lower recurrence with open stabilization. For athletes with greater than 20% to 25% bone loss, an open osseous augmentation procedure should be considered.

Combined lesions of the glenoid labrum.

Abstract Advances in shoulder arthroscopy and improved understanding of the pathoanatomy following shoulder instability have led to increased recognition of combined lesions of the glenoid labrum. Although the diagnosis of combined labral tears is often made with physical examination and magnetic resonance imaging, combined tears can be discovered intraoperatively. A high index of suspicion is necessary, especially in the setting of chronic recurrent shoulder instability or previous failed labral repair. Over a 6-year period at a military institution, combined labral repairs comprised 37% of all patients undergoing any labral repair. With accurate identification of all labral pathology and a systematic approach to labral repair, successful outcomes can be achieved.

Circumferential Labral Tears Resulting From a Single Anterior Glenohumeral Instability Event A Report of 3 Cases in Young Athletes

Accurate identification of the pathoanatomy after shoulder instability events guides surgical treatment. Detachment of the capsuloligamentous complex from the glenoid rim (Bankart lesion), impression fracture of the posterolateral humeral head (Hill-Sachs lesion), superior labral anterior and posterior (SLAP) lesions, attenuation of the capsular ligaments, disruption of the subscapularis tendon, and humeral avulsion of the inferior glenohumeral ligaments (HAGL) have all been described after shoulder instability events and contribute to recurrent instability. The pathoanatomy most frequently encountered after a first-time anterior shoulder dislocation in a young athlete has been characterized as a Bankart lesion in 87% to 100% of patients and a Hill-Sachs lesion in 64% to 100% of patients. Recently, the pathoanatomy of first-time anterior subluxation events was also defined, showing a high proportion of Bankart and Hill-Sachs lesions as well. Combined lesions, including triple labral lesions involving avulsions of the anterior, posterior, and superior labrum, have been increasingly recognized and reported. In 1 recent series, 6.5% of all patients who underwent labral repair had a triple lesion, and 28.8% had combined lesions—lesions of the glenoid labrum in more than 1 functional area (eg, Bankart-SLAP). Circumferential (360 ) tears of the glenoid labrum, defined by complete detachment of the labrum from the glenoid, were first described by Powell et al as a type IX panlabral lesion. Lo and Burkhart retrospectively reviewed 7 patients with triple labral injuries (combined SLAP, Bankart, and reverse Bankart lesions) and 2 of these patients had circumferential labral tears without any area of labral attachment to the glenoid. Both patients were noted to have chronic recurrent instability. In the largest series of circumferential labral tears, Tokish et al reported that all 39 patients had a history of chronic recurrent anterior and/or posterior shoulder instability. We present 3 cases of circumferential labral tears after an isolated, first-time, traumatic anterior shoulder instability event. All 3 cases presented to a single surgeon (B.D.O.) during a 1-year period. We are unaware of other reports of circumferential labral tears occurring after a single instability event.